Medical Intake

Hello, friend. Thank you for taking a moment to fill out our health intake. Your safety is our utmost priority, so please complete the information as clearly as possible. Anything you share with us is 100% confidential.

First name

Last name

Email

Phone Number

How did you hear about us?

Web Search

Social Media

Friend

Other

Have you ever experienced psychedelics before?

No, never.

Yes, in a recreational setting

Yes, in a ceremonial setting

If you answer yes to the above, please describe a bit more about your previous experiences, including which medicine, dosage, and setting.

Have you ever been hospitalized for any of the above?

Yes

No

Have you ever had any issues with your blood pressure?

Yes

No

A healthy (less than 140/90) and recent blood pressure reading (within the last 6 months) is required for attendance.

What was your most recent blood pressure reading?

When was this reading taken?

Do you have any family history of any of the above conditions? If yes, please explain.

Are you taking any prescribed medications? If yes, please specify name and dosage for each medication, and how long you've been taking it.

Are you taking any non-prescribed medications, including herbs and supplements? If yes, please specify name and dosage for each medication, and how long you've been taking it.

Do you have any allergies? If yes, please specify.

Have you ever been diagnosed, treated, or self-identified with a substance use dis-harmony (disorder)?*

Drugs

Alcohol

Activities (shopping, eating, pornography, etc)

N/A

If you answered yes to the question above, please provide additional information about your experience including the date(s) or time span of your addiction, whether you have undergone any therapy or rehabilitation to heal, current status or time abstinent

Do you a family history of any of the above conditions? If so, please specify.

Are there any other traumatic incidents in your life you'd like us to know about?

Have you experienced any of the following?

Religious / Cult trauma

Sexual Trauma

If you answered "yes" to the above question, please explain as much as you feel comfortable sharing.

Do you have any known intolerance to any of the following?

Incense / aromatic smoke

Shakers / rattles

Darkness

What would you say is your greatest challenge in life right now?

What is your primary intention for joining a this retreat?

I formally attest, to the best of my knowledge and ability, that I have fully disclosed everything openly and honestly on this form, for the sake of my own safety and the safety of others

I understand that based upon my answers provided, I may be asked to book an additional medical clearance from Sacred Counsel’s chosen medical doctor, wherein I will be charged an additional $250 fee (not included in the retreat cost) for the medical appointment.

Sacred Counsel

Integrative Psychedelic Support

Medical Intake